asynchronous pacemaker an implanted pacemaker that delivers stimuli at a fixed rate, independent of any atrial or ventricular activity; this type is now rarely used except to initiate or terminate some tachycardias.

AV sequential pacemaker an implanted pacemaker with dual chamber pacing that maintains the atrial part of ventricular filling by stimulating the atrium if it does not respond at the proper interval after ventricular activity; used for patients with abnormal sinus node function or decreased atrioventricular conduction.

cardiac pacemaker a small mass of specialized muscle tissue in the heart that sets a rhythm of contraction and relaxation for the other parts of the heart, resulting in the heartbeat. Usually the pacemaker site is the sinoatrial node, near the junction with the superior vena cava. The normal rhythm, 60 to 100 contractions per minute, increases during physical or emotional stress and decreases during rest. The pace varies from person to person and is affected by abnormal conditions such as heart injuries and generalized infections. If the normal pacemaker fails to function, its regulating task may be taken over by another small mass of special muscular tissue, the atrioventricular node.

demand pacemaker an artificial pacemaker that activates only when it receives sensations indicating a lack of adequate spontaneous rhythm by the heart. It thus avoids competition with the patient's own natural pacemaker.

dual chamber pacemaker an implanted pacemaker having two leads, one in the atrium and one in the ventricle, so that electromechanical synchrony between the chambers can be approximated. Called also DDD pacemaker.

A dual chamber pacemaker senses and paces in both the atrium and the ventricle.

phrenic pacemaker the device used in electrophrenic respiration; it converts radiofrequency signals into electrical impulses that stimulate the phrenic nerve, resulting in descent and flattening of the diaphragm and improved inhalation of air. Called also diaphragmatic pacemaker.

synchronous pacemaker an implanted pacemaker that synchronizes the physiological events in the atrium with those of the ventricle; it stimulates the ventricle when triggered by the P wave from the atrium.

transcutaneous pacemaker a temporary pacemaker in which large surface, high impedance electrodes are applied to the anterior and posterior chest walls to deliver high current stimuli of long duration for pacing of the ventricles.

transvenous pacemaker an artificial pacemaker, either external or implanted, that is connected to the heart by pacing leads passed through the venous circulation to make contact with the endocardium of the right atrium or right ventricle.

uterine pacemaker either of the two regulating centers that control uterine contractions, located near the openings of the fallopian tubes. When the fetus is ready to be born the pacemakers set off a series of rhythmic contractions in the uterine muscle that gradually force the infant out into the birth canal.

wandering pacemaker a condition in which the site of origin of the impulses controlling the heart rate shifts from the head of the sinoatrial node to a lower part of the node or to another part of the atrium.

pace·mak·er

(pās'māk-ĕr),

1. Biologically, any rhythmic center that establishes a pace of activity.

2. An artificial regulator of rate activity.

3. In chemistry, the substance of which the rate of reaction sets the pace for a series of chain reactions; the rate-limiting reaction itself, for example, in a metabolic pathway, the enzyme catalyzing the slowest or rate-limiting reaction in that pathway.

[L. passus, step, pace]

pacemaker

/pace·mak·er/ (pās´māk″er)

1. that which sets the pace at which a phenomenon occurs.

2. the natural cardiac pacemaker or an artificial cardiac pacemaker.

3. in biochemistry, a substance whose rate of reaction sets the pace for a series of related reactions.

artificial cardiac pacemaker a device designed to reproduce or regulate the rhythm of the heart. It is worn by or implanted in the body of the patient, is battery-driven, is usually triggered or inhibited to modify output by sensing the intracardiac potential in one or more cardiac chambers, and may also have antitachycardia functions. Many are designated by a three to five letter code used to categorize them functionally.

cardiac pacemaker a group of cells rhythmically initiating the heartbeat, characterized physiologically by a slow loss of membrane potential during diastole; usually it is the sinoatrial node.

demand pacemaker an implanted cardiac pacemaker in which the generator stimulus is inhibited by a signal derived from the heart's electrical activation (depolarization), thus minimizing the risk of pacemaker-induced fibrillation.

dual chamber pacemaker an artificial pacemaker with two leads, one in the atrium and one in the ventricle, so that electromechanical synchrony can be approximated.

ectopic pacemaker any biological cardiac pacemaker other than the sinoatrial node; it is normally inactive.

escape pacemaker an ectopic pacemaker that assumes control of cardiac impulse propagation because of failure of the sinoatrial node to initiate one or more impulses.

fixed-rate pacemaker an artificial cardiac pacemaker set to pace at only a single rate.

rate responsive pacemaker an artificial cardiac pacemaker that can deliver stimuli at a rate adjustable to some parameter independent of atrial activity.

single chamber pacemaker an implanted cardiac pacemaker with only one lead, placed in either the atrium or the ventricle.

wandering atrial pacemaker a condition in which the site of origin of the impulses controlling the heart rate shifts from one point to another within the atria, almost with every beat.

pacemaker

(pās′mā′kər)

n.

a. A part of the body, such as the mass of muscle fibers of the sinoatrial node, that sets the pace or rhythm of physiological activity.

b. Any of several usually miniaturized and surgically implanted electronic devices used to stimulate or regulate contractions of the heart muscle.

pace′mak′ing adj. & n.

pacemaker

Etymology: L, passus, step; AS, macian, to make

1 the sinoatrial node composed of specialized nervous tissue and located at the junction of the superior vena cava and the right atrium. It initiates the contractions of the atria, which transmit the impulse onto the atrioventricular (AV) node, thereby initiating the contraction of the ventricles. An ectopic or idioventricular pacemaker, originating in the atria, AV node, or ventricle, may cause contractions in cases of abnormal heart functioning. Also called cardiac pacemaker.

2 an electric apparatus used in most cases to increase the heart rate in severe bradycardia by electrically stimulating the heart muscle. A pacemaker may be permanent or temporary, emit the stimulus at a constant and fixed rate, or fire only on demand.

pace·mak·er

1. Biologically, any rhythmic center that establishes a pace of activity.

2. An artificial regulator of rate activity.

3. chemistry The substance with a rate ofreaction that sets the pace for a series of chain reactions.

[L. passus, step, pace]

pacemaker

(pas'mak?er)

1. Anything that influences the rate and rhythm of occurrence of some activity or process.

2. In cardiology, a specialized cell or group of cells that automatically generates impulses that spread to other regions of the heart. The normal cardiac pacemaker is the sinoatrial node, a group of cells in the right atrium near the entrance of the superior vena cava.

3. A generally accepted term for artificial cardiac pacemaker.

PACEMAKER: Pacemaker defibrillator beneath the skin

artificial cardiac pacemaker

A device that can trigger mechanical contractions of the heart by emitting periodic electrical discharges. If the device delivers electricity through the chest wall, it is called a transcutaneous pacemaker; if it works via electrodes inserted inside the body, it is called an internal or implantable pacemaker. Pacemakers are used most often to treat patients with symptomatic slow heart rates or long pauses between heart beats (such as patients with third-degree heart block, symptomatic second-degree heart block, bifascicular block with first-degree heart block, carotid sinus hypersensitivity, and tachybrady syndrome) and slow ventricular response rates. Occasionally, though, they also are used for other purposes, such as to capture and override some tachyarrhythmias. See: illustration

All artificial cardiac pacemakers have a pulse generator (a device that gives off an electrical impulse at prescribed intervals), electrical leads (which transmit the impulse to the myocardium), and a battery (usually made of lithium iodide) encased in titanium and implanted surgically in a subcutaneous pocket (usually in the chest). The pacing leads are threaded through a subclavian vein into the right heart, with the primary lead placed in the ventricle, and the second lead (if required) in the atrium. For biventricular pacing, a third lead is placed in the left ventricle. A biventricular pacemaker also may have a built-in cardiovertor-defibrillator. Pacemakers typically have the ability to pace the ventricle, the atrium, or both; to sense electrical discharges coming from cardiac chambers; and to respond to sensed beats. Most pacemakers in the U.S. also are programmable, and many are rate responsive. The features of each pacemaker are identified in its three- to five-letter NASPE/BPG code (developed and revised by the North American Society of Pacing & Electrophysiology and the British Pacing & Electrophysiology Group). The five positions describe the pacer's functions as follows:1. Chambers paced (O=none, A=atrium, V=ventricle, D=dual [atria and ventricles], S=manufacturer's designation for single [atrium or ventricle]; 2. Chambers sensed (O=none, A=atrium, V=ventricle, D=Dual, S=Single; 3. Response to sensed event (O=none, T=triggered, I=inhibited, D=dual [inhibited and triggered]; 4. Rate modulation (O=none, R=rate modulation in response to sensor technology; 5. Multisite pacing (O=none, A=atrium, V=ventricle, D=dual [atrium and ventricle]).Thus a pacemaker with the letter I in position 3 of its code will inhibit firing when it senses an intrinsic beat but will pace the cardiac chamber if no beat is sensed. The letter D in position 5 indicates that both atria and both ventricles are paced, with the left and right chambers stimulated simultaneously to maintain coordination and thus improve cardiac output. When the pacemaker has a rate modulation feature (R in position 4), also known as an adaptive rate mechanism, it works to copy the abilities of a normally functioning heart, such as detecting exercise and triggering pacer rate acceleration to meet the increased metabolic need. Other pacemaker features include hysteresis, which delays unnecessary pacing (which can harm the right ventricle), and allows the patient's intrinsic impulse to provide an atrial kick, which stokes the ventricle and increases cardiac output by 15% to 30% over a beat without atrial kick. Pacers with a “rate-smoothing algorithm” limit heart rate changes to a programmed percentage from one beat to the next, allowing the heart rate to increase or decrease more slowly and providing time for the body to adjust the stroke volume as it would normally in such situations.

Patient care

After pacemaker implantation, follow-up care is provided to ensure that the device is working optimally. A chest x-ray confirms correct placement of the leads and also can identify some complications, such as pneumothorax. Since pacemakers usually are implanted under moderate sedation and analgesia, the patient may still be drowsy on return to the unit from recovery; however, he/she should arouse easily and be able to answer questions and follow commands. Supplemental oxygen is provided (nasal cannula or mask) until the patient is fully awake and his/her oxygen saturation has returned to baseline. Immobilizing the patient's shoulder and arm on the operative side with a sling or ace-wrap for 24 to 48 hr limits movement that could dislodge the tip of the pacing electrode(s) from the endocardial wall, preventing sensing of intrinsic beats or needed pacing. The incision is assessed for bleeding, infection, and incisional discomfort, which is controlled with prescribed analgesia. The patient also is assessed for chest pain, palpitations, dizziness, shortness of breath, hiccuping, and a sensation of pacing in the abdomen, and the cardiologist or surgeon notified if any of these occur. The chest x-ray usually is repeated the following day to document positioning and rule out pneumothorax. Pacer function is checked, and the patient discharged with instructions for activity restrictions and further care. Follow-up care typically includes monitoring the pacemaker's performance, either in the cardiologist's office or by telephonic link-up to ensure, for example, that the pulse generator is triggering a heart rate that is appropriate for the patient's needs, that the leads are working, and that the battery's strength is adequate.

Health care professionals should ascertain the type of pacemaker employed and expectations for its function based on its NASPE/BPG code; monitor the cardiac rate and rhythm for evidence of pacemaker function; assess the patient for evidence of pacemaker failure or noncapture (vertigo, loss of consciousness, hypotension, chest discomfort, dyspnea) and evaluate the patient for effects on cardiac output; teach the patient technique and rationale for monitoring own pulse rate and for care and protection of insertion site; and counsel concerning telephone monitoring check-up, battery replacement, medication regimen, physical activity, and follow-up care. They should encourage the patient to wear or carry medical identification and information indicating the presence and type of pacemaker implanted, along with an electrocardiogram rhythm strip showing pacemaker activity and capture.

CAUTION!

Patients with artificial cardiac pacemakers should avoid MR imaging.

breathing pacemaker

A device that stimulates breathing by delivering electrical pulses to both phrenic nerves from an external radio transmitter to an implanted receiver. It is used in patients with quadriplegia or sleep apnea. See: radiofrequency electrophrenic respiration

DDD pacemaker

A rate-adaptive implanted pacing device. It senses and paces both atrial and ventricular events, triggering the atrioventricular (AV) interval so that AV synchrony is maintained over a wide range of heart rates. This type of pacing has reduced the incidence of pacemaker syndrome. It is the most versatile pacing device used. See: pacing code; pacemaker syndrome

DDI pacemaker

An implanted pacing device that senses both atrial and ventricular events but can inhibit only atrial impulses. This type of pacing is used only when atrioventricular conduction is intact. It may be suitable when frequent atrial tachyarrhythmias cause rapid ventricular rates.

demand pacemaker

An implanted pacemaker that is designed to permit its electrical output to be inhibited by the heart's electrical impulses. This decreases the chances for the pacemaker to induce discomfort or dysrhythmias.

dual-chamber pacemaker

A pacemaker that is also known as an atrioventricular sequential pacemaker because it stimulates both atria and ventricles sequentially.

ectopic pacemaker

Any endogenous cardiac pacemaker other than the sinoatrial node.

fixed-rate pacemaker

A pacemaker that stimulates the heart at a predetermined rate.

internal pacemaker

A cardiac pacemaker placed within the body.

permanent pacemaker

An electronic device for permanent cardiac pacing. The leads are usually inserted transvenously through the subclavian or cephalic veins with leads positioned in the right atrium for atrial pacing or in the right ventricular apex for ventricular pacing. The leads are connected to the pulse generator, which is implanted in a subcutaneous pocket below the clavicle.

programmable pacemaker

An electronic permanent pacemaker in which one or more settings can be changed electronically.

rate-responsive pacemaker

An electronic pacemaker that senses changes in the body's need for adjustment of the cardiac rate as can occur in sleeping, waking, sitting, walking, or running. The device alters cardiac rate by sensing body motion, changes in breathing, or slight changes in blood temperature, which improves the quality of life for active patients. It is also called a rate-adaptive pacemaker.

temporary pacemaker

An electronic device for temporary cardiac pacing (e.g., during cardiac surgery and emergencies). The device consists of an electrode catheter inserted transvenously in the right ventricular apex that receives impulses from an external generator.

transcutaneous pacemaker

An artificial cardiac pacemaker that is located outside the body. The electrodes for delivering the stimulus are located on the chest wall. Synonym: transthoracic pacemaker

pacemaker

Pacemaker

An electrical device that has electrodes attached to the heart to electrically stimulate the heart to beat normally. Pacemakers can be internal (placed under the skin) or external, with the electrodes placed on the skin or threaded through a tube placed into the heart.

pacemaker

the region of the heart, normally the sinoatrial node, that rhythmically initiates the cardiac action potential and hence the whole electrical and mechanical cardiac cycle, varying the heart rate under the influence of the sympathetic and parasympathetic nerve supply. An artificial pacemaker may be implanted when normal rhythm generation is affected by heart disease.

pacemaker,

n1. the sinoatrial node comprises specialized tissue and is positioned at the junction of the right atrium and superior vena cava; primar-ily responsible for initiating the contractions of the atria which transmit the impulse to atrioventricular node resulting in contraction of the ventricles. A pacemaker that does not function properly may cause irregularities in the function of the heart. 2. an electrical device that is temporarily or permanently implanted in the body to improve the heart rate by using electric impulses to stimulate the heart muscles. Also called cardiac pacemaker.

pace·mak·er

(pās'mā-kĕr)

1. Biologically, any rhythmic center that establishes a pace of activity.

2. An artificial regulator of rate activity.

[L. passus, step, pace]

pacemaker,

n an electrical device used to maintain a normal sinus rhythm in heart muscle contraction. Pacemakers can be permanent indwelling appliances. The use of electronic devices on patients with pacemakers is now considered permissible because of modern shields. The device may also have a defibrillator. Also called cardiac pacemaker.

pacemaker

1. an object or substance that controls the rate at which a certain phenomenon occurs; often used alone to indicate an artificial cardiac pacemaker; however, there are other natural and artificial pacemakers.

2. In biochemistry, a pacemaker is a substance whose rate of reaction sets the pace for a series of interrelated reactions.

asynchronous pacemaker

(1) an implanted cardiac pacemaker in which the induced ventricular rhythm is independent of the atrium; it is usually set at a fixed rate of ventricular stimulation.

pacemaker cells

(1) cells within the heart capable of spontaneous discharge.

gastric pacemaker

(1) a saddle-shaped area of the greater curvature of the stomach at the junction of its proximal and middle thirds, which regulates the frequency of gastric contractions.

phrenic pacemaker

(1) a device designed to facilitate respiration by converting radiofrequency signals into electrical impulses that stimulate the phrenic nerve, resulting in contraction and flattening of the diaphragm and improved inspiration of air.

pacemaker therapy

implantation of a pacemaker device in animals usually for the treatment of symptomatic bradyarrhythmias.

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